Our organization sought to develop reporting methodologies that allow senior leaders to prioritize improvement opportunities based on the frequency and severity of negative outcomes and compare performance with peer hospitals at a complication-specific level.
Three approaches were used.
- First, PSI 04 was used to provide a broad view of organizational and peer group comparative performance.
- Then, complication-specific metrics were developed and employed to enable the identification of specific areas of opportunity for improvement.
- Finally, performance tracking for individual complications was implemented to monitor the stability and impact of improvement efforts over time.
We were then able to establish a monthly process for analysis and reporting hospital-level complication-specific performance.
This analysis and reporting is based upon 100% of patients discharged from inpatient (non-hospice) units and provide comparative analysis from benchmark organizations to facilitate comparative analyses of Crude Mortality Rate, Observed to Expected Mortality (O/E) (VIZIENT), Monthly Case Mix Index (CMI), and Mortality Rate per complication (%) for Gastrointestinal Bleeding, Pulmonary Embolism, Pneumonia, Sepsis, Shock and Myocardial Infarction, Respiratory Failure, and Kidney Failure.
The monthly data for sepsis, shown below, provides an example of the charts created for each complication to visualize performance over time, performance stability, and comparison with other like institutions.
G. Blike, I. Perreard, K. McGovern, and S. McGrath, “A Pragmatic Method for Measuring Inpatient Complications and Complication-Specific Mortality,” J. Patient Saf., vol. Publish Ahead of Print, Feb. 2022, doi: 10.1097/PTS.0000000000000984.